Atypical middle ear mass: botriomycoma simulating a tympanojugular glomus (case report)

¹Otorhinolaryngology Department, Military Training Hospital Mohamed V, Rabat, Morocco

^&Corresponding author
Marouane Balouki, Otorhinolaryngology Department, Military Training Hospital Mohamed V, Rabat, Morocco

Introduction    

Tumors of the middle ear present a wide range of benign and malignant histology and must always be characterized histologically and radiologically. Botriomycoma is a common, highly vascular, solid tumor, often occurring in patients after the fifth decade which must be considered in the differential diagnosis, even in some rare sites [1].

Patient and observation     

Patient information: a 53-year-old man, without particular history, who was presented to the ear, nose, and throat (ENT) emergency with a low abundance left otorrhagia associated with tinnitus and deafness on the same side without dizziness. Otoscopy showed a vascular-looking mass in the external auditory canal emerging from the tympanic cavity and bleeding on contact (Figure 1).

Diagnostic assessment: the CT scan of the rocks showed a mass of tissue filling the left external auditory canal, the tympanic cavity, the attic and the antrum associated with an eburnation of the mastoid cells and respecting the ossicular chain, the wall of the cubicle and the tympani and antri tegmens (Figure 2). Magnetic resonance imaging of the middle ear revealed a left tympano-jugular lesion with tissue appearance, intensely and heterogeneously enhanced, producing a salt pepper appearance in favor of a tympano-jugular paraganglioma (Figure 3).

A biopsy of the intraductal mass was performed under local anesthesia and under endoscopic guidance. Histological examination was in favor of tympanic botriomycoma without sign of malignancy. Therefore, despite the radiological characteristics of the mass which were in favor of a tympano-jigular paragonglioma, the histological test posed another differential diagnosis of tympanojigular vascular tumors.

Therapeutic interventions: the patient underwent a surgical exeresis of the mass by the transcanal way under general anesthesia. A recess of the tympanic cavity was made with a tympanoplasty by a cartilaginous graft.

Follow-up and outcome of interventions: there was no complication diagnosed. After three months, the functional outcome was satisfactory: the evolution was marked by clinical and audiometric improvement; the otorrhagia and the tinnitus disappeared and the rhine of the transmissive deafness decreased.

Patient perspective: after the complete exercise of the mass, the clinical condition improved markedly, with disappearance of earache and tinnitus and recovery of hearing.

Informed consent: informed consent was obtained from the patient.

Discussion     

Botriomycomas are much less common in the middle ear than glomus tumors. These are slowly evolving and that develop from neuroendocrine cells extrasurrenal paraganglioma. They manifest often conductive deafness and tinnitus pulsatile testifying to its essentially vascular nature. Imaging plays an essential role in the diagnosis positive and based on computed tomography (CT) and imaging magnetic resonance (MRI) [2].

The clinical signs (pulsatile tinnitus and conductive hearing loss) and radiological (radiological appearance in salt pepper) reported by our patient were in favor of a jugulo tympanic paragonglioma. According to radiologists Atmane et al. the computed tomography (CT) scan diagnosis of jugular and tympanic glomus is easy if one demonstrates a rounded tissue mass, adherent to the protuberance without bone alteration of the medial walls and / or lower middle ear with respect to the floor of the hypo tympanum. Injection of the product contrast shows intense contrast enhancement of the mass affirming the vascular nature of the tumor [2].

MRI allows better tissue characterization. It then takes on its full value, showing the intermediate signal of the wrong process. Individualized from neighboring serous otitis. The lesion is slightly hyperintense in T2, iso-intense in T1. It´s characterized by a significant increase in contrast after intravenous injection of contrast medium. The "salt and pepper" appearance characteristic of large glomus tumors, generated by signal voids corresponding to sections of fast-flowing vascular structures, is often not found for patients with small tumors. MRI can differentiate the tumor compartment from retention lesions associated serosa and specifies the tumor extension in coronal and sagittal planes [3,4].

Based on these radiological elements identical to those observed in our patient, we were more oriented towards a paragonglioma. However, the biopsy and the histological examination made it possible to correct the retained diagnosis. The diagnosis of botriomycoma is essentially histological, showing an inflammatory infiltrate associated with capillary proliferation. The lobular appearance of this vascular proliferation is characteristic [5].

The curative treatment of vascular tumors can only be surgical, either retro auricular or endocanal route, which allows a recess of the tympanic body, an exploration of the continuity of the ossicular chain and a tympanoplasty lastly [5].

Conclusion     

Botriomycoma of the middle ear extended to the external auditory canal gives the same clinical and radiological picture of jugulotympanic paragonglioma, which poses a diagnostic challenge. The histological examination is the only paraclinical examination which makes it possible to differentiate between these two vascular tumors.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

MB wrote the article. MZ, NE and BH have reviewed the literature. SO, AJ and FB are responsible for the corrections. All authors have read and approved the final manuscript.

Figures     

Figure 1: endoscopic view of the left ear showing a vascular-looking mass originating from the middle ear and extending into the external auditory canal

Figure 2: (A, B) the CT scan of the rocks showed a mass of tissue filling the left external auditory canal, the tympanic cavity, the attic and the antrum associated with an eburnation of the mastoid cells and respecting the ossicular chain, the wall of the cubicle and the tympani and antri tegmens

Figure 3: T1-weighted axial MRI after intravenous injection of contrast product (A) and coronal T2-weighted (B) showing a process tumor of intermediate signal, heterogeneous, achieving an aspect in "pepper and salt" and intensely enhancing after injection of gadolinium, filling the external auditory canal and the left otomastoid cavities respecting the inner ear

References